Injectable Hydrocortisone Dosing in Children
For pediatric adrenal crisis, administer hydrocortisone 2 mg/kg IV/IM immediately (maximum 100 mg), followed by continuous infusion or repeated dosing every 6 hours based on weight and severity. 1
Adrenal Crisis Management
Initial Bolus Dosing
- Administer hydrocortisone 2 mg/kg IV or IM immediately as the initial bolus dose 1
- This translates to approximately 10-15 times the physiological replacement dose needed for life-threatening adrenal insufficiency 2
Continuous Infusion Protocol (Weight-Based)
After the initial bolus, start continuous IV infusion immediately: 1
- Up to 10 kg: 25 mg per 24 hours
- 11-20 kg: 50 mg per 24 hours
- Over 20 kg (prepubertal): 100 mg per 24 hours
- Over 20 kg (pubertal): 150 mg per 24 hours
Alternative Intermittent Dosing
If continuous infusion is not feasible, administer hydrocortisone 2 mg/kg every 4-6 hours IV or IM 1
Critical Pitfall
Do not delay administration while attempting IV access—give IM immediately if peripheral access cannot be secured quickly 2
Anaphylaxis/Severe Allergic Reaction
Age-Specific Dosing
Hydrocortisone serves only as adjunctive therapy after epinephrine (which must be given first at 0.01 mg/kg IM): 3, 4, 5
- Under 6 months: 25 mg IM or IV 3
- 6 months to 6 years: 50 mg IM or IV 3, 4
- 6-12 years: 100 mg IM or IV 3
Alternative Corticosteroid Regimens
- Methylprednisolone 1-2 mg/kg IV (maximum 60-80 mg) can be substituted 3
- Prednisone 0.5-1 mg/kg orally for stable patients being discharged (maximum 60 mg) 3
Important Context
Corticosteroids provide no acute benefit in anaphylaxis—they only potentially prevent biphasic reactions occurring 4-12 hours later 3, 5. Never delay or replace epinephrine administration with steroids 3, 4, 5.
Status Asthmaticus
Dosing Protocol
- Hydrocortisone 5 mg/kg IV every 6 hours for severe acute asthma 6
- This maintains plasma hydrocortisone levels at 100-150 mcg/dL, which is therapeutic for bronchospasm 6
Clinical Evidence
Hydrocortisone shows slowly evolving improvement over 4 hours rather than immediate bronchodilation 6. It significantly enhances responsiveness to beta-agonists like epinephrine or albuterol 6.
Guideline-Based Alternative
The 1993 British Thoracic Society guidelines recommend intravenous hydrocortisone for children with life-threatening asthma features (though specific pediatric doses are not detailed in the provided excerpt) 1
Refractory Shock
Dosing for Septic Shock with Adrenal Insufficiency
- Absolute adrenal insufficiency (peak cortisol <18 mcg/dL): Use titrated hydrocortisone 2-50 mg/kg/day to reverse catecholamine-resistant shock 7
- Relative adrenal insufficiency in children: Evidence is insufficient to recommend routine low-dose hydrocortisone (5 mg/kg/day) as used in adults—more pediatric studies are needed before widespread adoption 7
Clinical Context
Children dying from fulminant meningococcemia show very low cortisol:ACTH ratios within the first 8 hours, suggesting adrenal insufficiency contributes to cardiovascular collapse 7. However, the pediatric literature remains cautious about routine stress-dose steroids in septic shock without documented adrenal insufficiency 7.
Key Clinical Pearls
Formulation Considerations
- Never crush or manipulate hydrocortisone tablets for pediatric dosing—this leads to highly variable dosing and potential iatrogenic Cushing syndrome 8
- Use pharmacy-compounded alcohol-free hydrocortisone suspension or injectable formulations for accurate pediatric dosing 8
Monitoring Requirements
- Correct fluid deficit, hypoglycemia, hyponatremia, and hyperkalemia concurrently with hydrocortisone administration in adrenal crisis 2
- Observe anaphylaxis patients for minimum 6 hours after steroid administration due to biphasic reaction risk 3, 4
Patient/Family Education
All patients with adrenal insufficiency should carry emergency hydrocortisone injection kits and receive self-injection training 2. Families must understand when to increase glucocorticoid doses during stress and how to recognize adrenal crisis 2.